Inspection on 16/07/08 for 17 Penland Road

This inspection was carried out on 16th July 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Insight - Eastchurch

Southfields

Thorndene

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33 St John`s Church Road

Dovedale Court

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 17 Penland Road 17 Penland Road Bexhill-On-Sea TN40 2JG Lead Inspector Caroline Johnson Unannounced Inspection 16th July 2008 09:35 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17 Penland Road Address 17 Penland Road Bexhill-On-Sea TN40 2JG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01424 730696 01424 751641 Hastings and Rother Primary Care Trust John Howatson Care Home 6 Category(ies) of Learning disability (0) registration, with number of places 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories 2. Learning Disability - LD The maximum number of service users who can be accommodated is: 6 N/A Date of last inspection Brief Description of the Service: 17 Penland Road is a detached two-storey property situated in a residential area on the outskirts of Bexhill on Sea. A large retail outlet with shops is within walking distance of the home and Bexhill town centre with its access to rail and bus services is approximately one mile away. The home is registered to accommodate six adults with a learning disability. Resident accommodation consists of six single bedrooms. Bathing and toilet facilities are provided by way of two bathrooms, a shower room and separate toilet. Communal areas comprise of a large lounge and separate dining room. A large garden is situated to the side and rear of the property. Parking is available at the front of the home. In April 2008 Hastings and Rother PCT became the registered providers for this service taking over form the Kent & Medway NHS and Social Care Partnership Trust. The Trust manages nine other homes within the Hastings, St Leonards and Rother area. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. For the purpose of this report the people living at 17 Penland Road will be referred to as ‘residents’. As part of the inspection process a site visit was carried out on 16th July 2008 and it lasted from 9.35 until 5.55pm. The registered manager facilitated the inspection. Over the course of the inspection there was an opportunity to meet and have lunch with four of the residents. In addition time was spent with two members of staff in private. A full tour of the home was undertaken. Two care plans were examined in detail. In addition records seen included; staff rotas, training, medication, menus, health and safety, quality assurance and leisure activities. In advance of the inspection process four service user surveys and four health care professional surveys were sent to the home to distribute. Three service user surveys were returned. Residents completed the surveys with some staff support in relation to understanding the questions. They were wholly positive with comments such as ‘Penland Road very good, I live here forever’ and X ‘is happy’. All of the residents said that they had ‘visits’ prior to moving to the home and they all knew to whom they would speak with if they were unhappy. One resident said they would write a letter. What the service does well: The home is well maintained and has been decorated to a very good standard. Each of the bedrooms have been personalised and reflect individual residents’ tastes and interests. Residents choose the décor for their room. The home is well located so it is easy to take residents for walks and to use local transport. Residents are offered a varied and stimulating range of activities and if for any reason an activity cannot take place it is replaced with a suitable alternative. The home is using each resident’s preferred method of communication when there is information to be relayed in a written format. For example one person likes information on their computer, some use audiotapes and some like it written with symbols. Support plans provide detailed information about the needs and abilities of residents and there are detailed guidelines in place to ensure that needs can be met effectively. As some of the residents have complex needs and the 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 6 home ensures that they seek professional advice and support. Staff support residents to keep in touch with their relatives. Staff advised that they are supervised regularly and feel well supported in their role within the home. What has improved since the last inspection? What they could do better: Two requirements were made as a result of this inspection. There are a number of training courses that have been identified as essential to work in the home and arrangements need to be made for all staff to attend training. In particular the majority of the residents use makaton but only one member of staff is trained in this area. Monthly visits carried out by the senior management team need to be more detailed, need to identify shortfalls observed, how they are being managed and any impact the shortfalls have on the quality of care received by the residents. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 7 Following the inspection the manager confirmed in writing the action to be taken to address the requirements made. In addition he confirmed a number of other improvements that have been made since the inspection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents receive information about the services on offer in a format that can be easily understood. EVIDENCE: As required at the last inspection the statement of purpose was updated and a copy was sent to the Commission. However due to the change of ownership the document is currently under review again. The manager advised that he is part of a working group whose remit is to update the statement of purpose, terms and conditions of residence and licence agreement with the housing provider. The updated version should be available within the next few weeks. The home has a detailed service user guide and this is also available both in large print and as an audio version. There is a pictorial complaints procedure in place, a copy of which is attached to the service user guide. At the time of inspection there were five residents accommodated. There have been no admissions to the home since the last inspection. There is a detailed assessment in place of each resident’s abilities and needs and this is updated at regular intervals. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 10 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The quality of the support plans in place is very good and with better record keeping in some areas this will be enhanced even further. EVIDENCE: Two support plans were examined on this occasion. The home has revised the format used to make it more person centred. An assessment of each resident’s needs has been carried out and there is detailed guidance included on how to meet all aspects of care. In each support plan there are both generic and person centred risk assessments in place. The manager also advised that there are now activity based risk assessments in place. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 12 There is a detailed handover sheet in place to ensure that all relevant information is passed from one shift to the next. In addition there is a daily record sheet in place where staff record what an individual did, who supported them, what worked well and what didn’t. The layout of this form does not allow for detailed information to be recorded and comments are very limited mainly relating to the mood of the individual such as ‘happy and relaxed’. As recommended at the last inspection a record is kept of all people invited to residents’ reviews and also if a copy of the minutes are provided. Four of the residents use makaton and some are competent up to level 10. One of the residents who can speak wanted to learn makaton as they wanted to be able to understand the other residents who use signing regularly. Progress with this goal is recorded. Residents have a makaton evening one evening a week and it was reported that everyone enjoys this session. Another resident’s goal is delivering mail to the head office and there are records showing progress with this goal. It was agreed that drawing up goals in a more person centred way and giving residents a copy of their identified goal could assist in motivating and encouraging greater participation in goal achievements. Historically the home have not had residents’ meetings but in May this year they had their first meeting. This meeting involved setting out how the meetings were going to be run and giving residents ideas for issues that could be discussed in this forum. At the first meeting a four-week menu was decided taking into consideration everyone’s wishes. In addition house issues were discussed. The manager advised that one of the residents has brought an issue to him that he would like discussed at the next meeting. However, for the meetings to be productive it is now becoming apparent that the meetings need to be held more frequently. Discussion was had about how the meetings could be used to demonstrate more clearly the choices and decisions made by the residents on a regular basis. One of the residents represents the home at all consultation meetings regarding trust issues. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a good range of varied and stimulating activities to meet their individual needs. EVIDENCE: MCCH staff provide day care activities for all residents in the home. At the time of inspection MCCH staff were working in the home three days a week. It was reported that although staff come to the home many of the activities provided are community based. Two of the residents go to the MCCH day centre two days a week for a basic skills course. Each of the residents has a weekly planner showing the planned activities for the following week. One resident is given his timetable on their computer and two residents have an audio planner. Other residents liked the audio planners 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 14 so much they asked if they could have one. At the time of inspection the home was just in receipt of the additional planners. The planners are designed like a photo album but with an audio commentary on each activity. One of the residents attends an evening arts course at Claverham. Other activities include aromatherapy, bowling, swimming, reading, cinema and music. As the home is close to the sea there are regular opportunities for walks on the seafront. At the time of inspection one of the residents was being supported to visit their relative in hospital on a daily basis. Staff also said that they support residents where necessary with contact with relatives and friends. In addition to some of the educational goals mentioned in the previous section each keyworker is now working with residents to identify opportunistic goals. Two residents receive additional staff support for short periods in particular circumstances such as for swimming trips, home visits or outings. This is reviewed at regular intervals and in relation to one resident the manager advised that as significant progress has been made since the last review he is anticipating that the additional staff support may no longer be necessary following the next review. All of the staff team are able to drive the house car. In addition all the residents have bus passes and a bus route operates from close to the home. As stated previously the four-week menu was decided at a residents’ meeting. Discussion was had about why it was felt it was needed to have a four-week menu. It was agreed that as long as someone monitors that residents are receiving a varied and balanced diet then it should be possible for residents to decide more regularly what they would like to eat. In order to fit in with shopping requirements this could be achieved on a weekly basis. The manager advised that residents do choose alternatives to the menu occasionally. One staff member stated that one resident occasionally goes to the freezer and takes out an alternative if he does not want what is on the menu. Changes to the set menu are recorded in an individual’s support plan. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good arrangements in place to ensure that the healthcare needs of the residents are met. EVIDENCE: The arrangements in place for the storage and handling of medication were in order. As part of induction to the service all new staff complete medication training. Once staff commence working in the home they are assessed on three occasions until they are deemed competent to administer medication in the home. Records are kept of all medication returned to the pharmacy and there are also records in place of all medication signed in/out as part of social leave. The manager advised that the pharmacist visits the home periodically to check on the storage and administration of medication. Some of the residents receive specialist advice and support in relation to their health care needs. Guidelines draw up by professionals are included in 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 16 individual support plans. Each of the residents has a health action plan in place and it is reviewed regularly to ensure that individual needs continue to be met. There was a very good rapport observed between staff and residents and there was a lively and jovial atmosphere in the home. One of the residents has died since the last inspection of the home. Staff advised that the residents coped well with their loss and those who chose to, were supported to attend the funeral. The Trust made available the option for all staff and residents to receive counselling and staff were offered a one-day course on death and dying. It was reported that the Community Learning disability Team are putting together a package on explaining death and dying specifically for people with learning disabilities. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are procedures in place to ensure that anyone wishing to make a complaint can do so. EVIDENCE: There is a detailed complaint procedure in place and in addition there is a simplified version of the procedure in place, which is also available in a range of formats. The manager advised that there have been no complaints since the last inspection. He stated that complaints must be made in writing, responded to within five days and the investigation must be concluded within twentyeight days. There is a hardbound book in place for recording complaints. Whilst it would be considered good to have a chronological list of all complaints recorded details of complaint investigations should be recorded separately and stored securely. There was one adult protection alert made since the last inspection. However, Social Services did not accept this as an alert and advised that no further action was necessary. The PCT has logged the incident as an SUI (Serious untoward incident) and are therefore carrying out an internal investigation. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 18 The home cares for people who at times can present with challenging behaviours. All of the staff team are trained in ‘PROACT SCIP’ manoeuvres but the manager advised that in three years he is only aware of a manoeuvre being used once. There are detailed arrangements in place for the managing of residents’ monies. Each resident has their own building society account and all their entitlements are paid directly into this account. On a monthly basis a cheque is drawn up to pay for rent. A small amount of money is held in-house to cover for daily spends. Detailed records are kept of all expenditure and copies of records are sent to head office. All money stored in the home is checked at three intervals throughout the day. Records were examined in relation to one resident and they were in order. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained and provides a good standard of accommodation for the residents. EVIDENCE: The building is well maintained and decorated to a good standard. The property is very spacious with a large lounge that leads out onto the garden area. The dining room is also a very spacious room and to the rear of the room there is a second lounge area. The floor in the dining room was replaced a week prior to the inspection. However, when the maintenance department had inspected this they decided that it wasn’t satisfactory so it will be redone again. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 20 There is a keypad lock on the kitchen door. Staff advised that residents can use the kitchen at any time provided there is staff support. A new shower tray is to be fitted in the shower room and a new bath panel in the bathroom. Bathroom areas are clean and generally well maintained but are not as homely as other areas of the house. All of the bedrooms are very individual and reflect the personalities and tastes of the residents. One resident has their own computer that they use regularly. Residents choose the colour scheme for their bedrooms when they are redecorated. There is a large garden to the side and rear of the property. At the time of the inspection there were a number of small flowerpots sunk in the ground so that the residents could practice pitch and putt in the garden. To the rear of the garden there are tables and chairs and a lovely water feature. Residents advised that they occasionally eat in the garden and that they like barbeques. Some of the residents prefer to eat in-doors. Residents use the laundry room with staff support. One resident is able to do their own ironing with some support. Two of the managers from other homes within the Trust are delegated trainers on the subject of infection control. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inadequate staff training in some key areas could affect the outcomes for some of the residents. EVIDENCE: It was reported that when the Trust took over in April 2008 all staff had to have a new CRB carried out. The manager advised that he checks each staff member’s car licence and insurance annually and if staff take residents out in their own car they must have business insurance cover. There are three staff on duty at all times and the manager’s hours are not included in theses numbers. Staff spoken with felt that the staff levels are sufficient to meet the needs of the residents. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 22 There is a training co-ordinator in place that advises the home on a monthly basis of the staff that need training updates in each area. Eight of the staff team have completed NVQ at level two or above and a further two staff are currently studying for the qualification. All new staff complete an induction week either prior to or shortly after commencing work in the home. During this induction they complete all mandatory training. Basic training consists of protection of vulnerable adults, first aid, fire safety, health and safety, infection control, basic food hygiene, communication, safe eating and drinking and medication training. During the first two weeks of employment in the home new staff are supernumerary, shadow an experienced member of staff and begin the home’s in-house induction. This includes being assessed on three occasions administering medication and completing a theory test before they are assessed as competent to administer medication. In addition arrangements are made for staff to attend any specialist training needed to equip them to work with the residents accommodated. Training that has been classed as essential for working at Penland Road includes epilepsy, visual impairment, makaton, scip, mca (mental capacity act), an introduction to autism and an introduction to mental health. Records showed that some of the staff team need to attend refresher courses in a number of the mandatory training areas. In relation to the essential training records showed that four staff need training on epilepsy but that all staff have completed training on scip and the mental health act. None of the staff team have completed makaton training. However, one staff member stated that she had completed a makaton course privately. As four of the residents use makaton and some to a high level it is essential that this training be provided as a matter of urgency. One resident who can speak has a goal in place to learn makaton, as they want to speak with the other residents using makaton and understand their signing. This goal is being carried out. The manager confirmed that a course has been booked for staff on an introduction to mental health and this will be held in September. None of the staff team have complete a course on autism. Staff spoken with during the inspection have worked in the home for a number of years and although have not received training in some of the key areas they had a good understanding of the needs of the residents and how they were supporting residents to meet them. Once new staff have completed the induction procedure they then go on to study for the Learning Disability Qualification, which is run via Hastings College. Staff that commence working in the home that have an NVQ in a related area will complete sections of the LDQ. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 23 The manager advised that one of the positive changes that has occurred since the new trust took over is that residents are now involved in staff selection. Three of the residents have recently been involved in meeting with applicants that were invited to the home for a second stage interview. All three were unanimous in their decision of which applicant they preferred and this was the person who was eventually chosen to work in the home. Staff spoken with confirmed that they receive regular supervision from either the manager or deputy. There is a chart on display in the office showing supervision dates. This was mostly up to date and showed that all staff had had at least two supervisions this year. All staff also have an annual appraisal of their performance. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run well in the interest of the residents accommodated. More robust quality assurance monitoring could enhance this even further. EVIDENCE: The registered manager is a registered nurse (RNLD) and has completed Managing Health and Social Care, postgraduate MESOL certificate. He advised that he receives regular supervision and support. Staff spoken with felt well supported by the manager. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 25 Staff meetings are held at least six times a year and there are also two away days. Records for the last staff meeting were very detailed, they showed good attendance and that clear guidance was provided from the manager and deputy about all changes to care practices. Some welcome changes as a result of the new Trust taking over include the fact that the manager is now supernummary, which means that he can concentrate on management tasks. In addition the home has a computer so this means that the manager does not have to go to the head office whenever administration tasks need to be undertaken. The manager advised that four months ago the trust completed a corporate action plan that they were then asked to read through and make it specific to the home. This work has been completed but the manager advised that it requires updating in a few areas. The manager advised that although it was a huge exercise it was very worthwhile and it now means that all staff know what they should be doing and when and there is clear evidence in place to show how the home is adhering to the national minimum standards. The manager advised that satisfaction questionnaires are due to be sent to relatives in the near future for their comments on the quality of the care provided in the home. They will be sent via the head office and the home will receive feedback of the outcome. A new procedure for seeking the views of the residents in relation to the care they receive has commenced and it is anticipated that this will happen each month with an individual resident. Records were seen of a recent questionnaire carried out with one resident. The practice development manager advised the home in advance of the visit and a staff member was able to sort out some photos to assist in communicating the questions to the resident. A number of the questions required a yes/no response and the pictures were used to enable the resident to make a choice of activities preferred or to point at a particular staff member in response to questions like would you know who to complaint to if you were unhappy. A staff member spoken with stated that knowing the questions in advance meant that she had time to plan the session in terms of the photos she needed. The more they use this process the better this will be as they will be able to take it further adapting questions for individuals and using a wider range of makaton signs and photos to seek opinions. A member of the senior management team is visiting once a month unannounced to report on the conduct of the home. Records showed that visits generally last one hour in duration. During this time, the assessor speaks with staff, with residents, checks through a care plan and also a wide range of documentation. Some good observations are reported but the auditing of the care plans appears to be statistics rather than outcome focussed. As the purpose of the visit is to report to the provider on the conduct of the home 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 26 and is seen as part of quality assurance the records do not show sufficient detail in relation to the quality of the care provided in the home both in terms of new improvements and achievements and in relation to shortfalls. The AQAA (annual quality assurance assessment) showed that a number of the policies and procedures had not been reviewed for some time. The manager advised that the Trust reviewed all the previous policies and procedures. A number have been removed and work is underway to update all the remainder. Some new policies have been updated since the AQAA was submitted to the Commission and as they are released to the home all staff have to read and sign that they have read and understood the revised policy. In advance of the inspection process four service user surveys and four health care professional surveys were sent to the home to distribute. Three service user surveys were returned. Residents completed the surveys with some staff support in relation to understanding the questions. They were wholly positive with comments such as ‘Penland Road very good, I live here forever’ and X ‘is happy’. All of the residents said that they had visits prior to moving to the home and they all knew to whom they would speak with if they were unhappy. One resident said they would write a letter. A staff member has been delegated to ensure that the COSHH file and guidance is kept up to date. It was reported that an audit is undertaken to ensure that all health and safety checks are up to date. Evidence from the AQAA shows that this has been achieved. It was also confirmed that the fire risk assessment had been reviewed and all recommendations made as a result have been carried out. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 2 X 3 3 X 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 28 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18(1) Requirement Timescale for action 15/10/08 2. YA39 26 The registered person must ensure that staff receive appropriate training to undertake their roles and the training provided is updated regularly. The registered provider must 30/09/08 ensure that more effective monitoring is achieved through Regulation 26 conduct visits of the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA7 Good Practice Recommendations The home should find ways of demonstrating more clearly how residents are making choices and decisions. 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 17 Penland Road DS0000071900.V368644.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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